Critically Appraised Topic: Bougie vs. ETT/Stylet Alone in 1st Attempt Intubation Success Rate


Summary of Methods & Findings:

Study #1: This was a randomized clinical trial of patients requiring intubation in an urban, academic emergency department in Minneapolis, Minnesota. The study was conducted from September 2016 through August 2017. Patients were eligible if they were 18 years and older who were consecutively admitted to the emergency department and underwent emergent orotracheal intubation with Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Exclusion criteria included prisoners, patients known or assumed to be pregnant, and patients with known distortion of the upper airway or glottic structures. The objective of the study was to compare first attempt intubation success facilitated by use of bougie versus endotracheal tube and stylet. Three hundred eighty-one patients were randomized to undergo initial intubation attempt facilitated by bougie and 376 randomized to undergo initial attempt by endotracheal tube and stylet. Patients were followed throughout the intubation process. Outcome data was recorded with primary outcome of first attempt-intubation success in patients with at least one difficult airway characteristic, defined as successful ET tube placement with first device passed. Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, duration of first-attempt, esophageal intubation, and hypoxemia. Of the 380 patients with at least one difficult airway feature, first-attempt success rate was higher in the bougie groups (96%) than in the endotracheal tube/stylet group (82%) (p<0.001). First-attempt success rate was also higher in the bougie group than endotracheal tube/stylet group when considering all patients (98% vs. 87%; p<0.001).  


Study 2: This was also a randomized controlled trial performed in the prehospital air medical setting of patients assigned to intubation via endotracheal tube introducer (ETTI) vs. standard orotracheal intubation (SOTI). Patients were included if they required intubation, were 12 years or older, and were intubated with at least 6.0 mm endotracheal tube. Exclusion criteria were those less than 12 or with incomplete data. The objective of the study was to prospectively evaluate the effectiveness of the ETTI versus SOTI in the prehospital air medical setting. Fifty-one patients were enrolled in the study across a 10-month period. Twenty patients were randomized to the ETTI group and 31 patients to the SOTI group. Primary outcome for the study was first-attempt success rate. Data was also collected on the number of intubation attempts until success, total intubation time, complications and laryngeal view encountered. First attempt success rate was 70% for ETTI group and 65% for SOTI group. There was no significant difference in the first-attempt success rate between the two groups (p=0.67) 



Both studies demonstrate a correlation between increased first-pass success rate and use of bougie for patients undergoing emergent intubation. Significant differences were demonstrated in the ED based study. Additional, larger studies should be performed across different institutions in order to determine generalizability of these findings and to demonstrate superiority of bougie use to intubation with endotracheal tube/stylet.  



Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. 

Heegaard WG, Black C, Pasquerella C, Miner J. Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting. Air Med J. 2003 Jan-Feb;22(1):28-31.